Pope Francis and Voices from the Congress

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PRESS STATEMENT. Pope Francis: “continue reflection and spread the Palliative Care practice”. Message to the Pontifical Academy for Life meeting in Rome and Voices from the Congress.

Rome, February 28th -. “The complexity and delicacy of the subjects present in palliative care require continuous reflection and the spread of the practice to facilitate access: a task in which believers can find like-minded companions in many people of good will”.   Pope Francis wrote this in the long message – signed by Cardinal Parolin, Secretary of State – sent on the occasion of the International Palliative Care Congress organised by the Pontifical Academy for Life that is taking place in Rome today and tomorrow. 

In the message - read out at the start of the session by Mgr. Renzo Pegoraro, Chancellor of the Pontifical Academy for Life – Pope Francis focused on pain relief. “Pope Pius XII – he explained – had clearly legitimized, by distinguishing it from euthanasia, the administration of analgesics to alleviate unbearable pain that is not otherwise treatable, even if, in the phase of imminent death, they may cause a shortening of life”. Today, the Pope admitted, “after many years of research, the shortening of life is no longer a frequent side effect, but the same question emerged with new drugs, which act on the state of consciousness and make different forms of sedation possible”. For the Pontiff, “the ethical criterion does not change, but the use of these procedures always requires careful discernment and great prudence.  Indeed, they are very demanding for the sick, for the family, and for carers: with sedation, especially when protracted and deep, the relational and communicative dimension that we have seen is crucial in accompanying palliative care is cancelled. It is therefore always at least partially unsatisfactory, so it must be considered as an extreme remedy, after having carefully examined and clarified the indications”.

 “It is significant in this regard – the Pontiff continued – that representatives of different religions and different cultures are present at your meeting, in an effort to deepen their shared commitment. In the training of healthcare workers, those with public responsibilities and in society as a whole it is important that these efforts be carried out together”. Emphasising the manifold dimensions that come into play in the practice of palliative care – scientific, organizational, relational and communicative skills, including spiritual accompaniment and prayer -, Pope Francis insisted on the importance of the family in this path. “It plays a unique role – he noted – as a place where solidarity between the generations presents itself as constitutive in the communication of life, and where mutual aid is experienced even in times of suffering or illness. Precisely for this reason, in the final stages of life, the family network, however fragile and disjointed it may be in today’s world, still constitutes a fundamental element”.

Voices from the Congress

Eduardo BRUERA University of Texas MD Anderson Cancer Center, Houston, Texas, USA

Palliative care teams have emerged as a response to the unmet need to patients and families. Interdisciplinary teams led by palliative care specialists have demonstrated efficacy in the inpatient, outpatient, and home care settings.

David Clark, Welcome Trust Investigator, School of Interdisciplinary Studies, University of Glasgow, Glasgow, UK

What conditions are necessary for the relationship between palliative care and society to become a ‘win win’ game?  The answer might lie in an overlapping consensus[i] that identifies the principles and concepts of palliative care that all stakeholders can share, when thinking through the complex challenges we now face. I take the view that palliative care can improve society, but not until it is clearer in its messaging and more confident of its efficacy.

Dr Marie-Charlotte Bouësseau, Adviser, Service Delivery and Safety World Health Organization, Genève, Switzerland

Building strong palliative care programs is like building a house. The basement of the house  is a clear policy on access to medicines.  The walls are made with good educational programs for health care workers fighting against “opiophobia” on one hand preventing over prescriptions of opioids in some countries. Health professionals need to be trained in many other aspects: managing symptoms of the disease and complications of the treatments, addressing psychological and spiritual needs of the patient and his/her family, providing information and facilitating advance care planning with an active participation of the patient and his/her family, coordinating interventions at all levels of care and task shifting within care providers, including family members. The door is made of national policies ensuring that palliative care is not limited to some specific programs but delivered across disease and age groups. Finally the roof of the palliative care house could be represented with the public debate which has to be fostered to take on board cultural, societal and ethical issues.

Kathleen M. Foley, Emeritus Professor of Neurology, Weill Cornell Medical College and Emeritus Member, Memorial Sloan-Kettering Cancer Center, New York, USA

The interdisciplinary team of physician, nurse, social worker, chaplain, psychologist, and pharmacist embrace the domains of whole person and patient- centered care  emphasizing the need to be present  to the sick person and their loved ones, providing unconditional support and solidarity, helping the patient achieve a sense of completion in life and finding opportunities for reconciliation, forgiveness, intimacy and  peacefulness. Palliative medicine is focused on treating those suffering with compassion and competence in an ethical and dignified paradigm that focuses on patients’  living well with serious illness, modeling  a way of caring that embodies the professionalism of medicine and constantly  challenging medicine to be better.   

Philip Larkin, University College Dublin, Dublin, Ireland

Europe is not a single entity, but a conglomeration of nations, cultures, beliefs and systems which global health ideals need to understand. Issues of social inequality, rural isolation, access to essential medications and immigration/migration are equal challenges for some European countries as the wider international community. The future integration of palliative care needs to be mindful of the future generation of practitioners to deliver on this particularly in terms of opportunity of education and training and employment in the field.

Egidio Del Fabbro, Virginia Commonwealth University, Richmond, Virginia, USA

Evidence shows patients with greater spiritual support may experience improved quality of life and fewer non-beneficial medical procedures near the end of life; skilled clinician communication regarding goals of care results in greater patient satisfaction and avoidance of mechanical ventilation and intensive care units; and a comprehensive clinical model of care that includes inpatient palliative care units and outpatient clinics improves patient and family satisfaction, quality of life, and decreases symptom burden. Studies have also identified challenging areas that will require increased resources, including a future PC workforce shortage and regions where access to PC is currently lacking, such as rural areas and those serving minorities.

Tania Pastrana, Latin American Palliative Care Association, San Nicolás, Argentina

​Latin America is one of the regions with the largest economic and social development gaps, including those related to access to health. In this presentation I will explore​ and describe​ the​ inequities in ​access to​ palliative care​ in the Region​​ and the strategies and possible solutions to meet these challenges.

Prof. Sr. Jinsun (Julianna) Yong, The Catholic University of Korea Director, WHO Collaborating Centre for Training in Hospice & Palliative Care, Seoul, South Korea

The level of hospice & palliative care development in Asia remains low. A survey conducted by the WHO CC for Training in Hospice & Palliative Care in four countries of the Asia-Pacific (Mongolia, Vietnam, Solomon Islands, and South Korea) revealed that the healthcare professionals’ perception of hospice & palliative care is rudimentary, while the cancer patients’ needs remain high. It is thus necessary to transform the professionals’ awareness to adequately address these needs, especially since cancer patients reported a high level of emotional and spiritual needs that are often neglected. In the Asia-Pacific, where most countries remain under such situation, providing holistic training to foster professional awareness on holistic care will have fundamental and sustainable effects for future development.

Emmanuel Luyirika, Executive Director African Palliative Care Association, Kampala, Uganda

Africa has 54 countries and a population of over 1 billion people. It has the highest burden of palliative care need. This is happening when health budgets in most countries have not reached 15% of the national budgets as they committed in the Abuja Declaration. Despite this challenges some progress is being made on the continent.

According to the 2017 APCA Palliative Care Atlas, at least 38 countries have some sort of palliative care service using different models. Uganda had 229 such services, South Africa 160 and Kenya 70. Only 16 countries have pediatric palliative care services. Swaziland has 10.88 hospice services per million of population, Uganda 5.87, Gambia 5.02 while South Africa 2.91 per million of population.

The challenges facing palliative care in Africa are inadequate to no funding in most countries, poor access to controlled medicines including morphine, few trained palliative care providers, not including palliative care professionals in the health establishment and lack of universal health coverage schemes including palliative care.

Azza Hassan, National Center for Cancer Care and Research, Doha, Qatar

Islamic societies, unlike several Western societies, are more death accepting, and live in coexistence with the realization of the inevitability of death. Such an attitude has an impact as to how a patient and his family may view death, also knowing what lies beyond it. Islamic teaching encourages the community members to visit the sick and the sick to welcome their guests. Patients, therefore, may entertain a larger number of visitors during their hospitalization. The use of drugs that might affect consciousness is strictly prohibited in Islam. However, medically prescribed opioids are generally permissible because of their necessity. Usually, patients and families accept the use of opioids for symptom management, provided the rationale for their use is clearly explained to them. Of great importance is to explain patients and their relatives the possible side effects, as there are great concerns about an imposed drowsiness. Issues that relate to end-of-life are compounded spiritually and ethically, and are open for interpretations.

Joby Kavungal, Catholic Health Association of India (CHAI), Cochin, Kerala, India

Currently, CHAI is one of the world's largest private not-for-profit Faith-Based Healthcare Networks, with a membership base of 3537 Member Institutions (MIs) - Over 90% of them are headed by women. Over 80% of CHAI member institutions, including 2331 health centres, 628 small, secondary and tertiary hospitals spread across all States – with a total of over 50,000 beds, etc. serve in the medically underserved areas where many a time not even primary public health facilities exist. It is estimated that, in India, about 6 million people need palliative care in a year. Only less than 2% of these people have access to palliative care that can relieve suffering. Moreover, there is also a tendency to exploit in the midst of sickness and dying, due to the growing commercialization of healthcare.  Responding to the situation, in collaboration with its member Institutions CHAI has launched the project Pratyasha - with a Model 25-bed Holistic Palliative Care Centre in Hyderabad with 6 Holistic Palliative Care Units (HPCUs) covering three states on a pilot hub & spokes model.

Katherine Pettus, International Association for Hospice & Palliative Care Advocacy Officer, Houston, Texas, USA

Palliative care advocacy requires clinicians to take the long view, the patient, faithful, eschatalogical perspective, maintained even as the sharp thorn of untreated patient and caregiver suffering drives us relentlessly on. Palliative care advocacy humbly requests public resources to care for people who don’t contribute to the bottom line, as a matter of justice, not of charity. We welcome guests who can’t reciprocate with their own party invitation. Such absurd petitions fly in the face of rational public policy and budgeting, particularly in this era of “scarcity” and “crisis.’

Rome, February 28th